Problems associated with the lack of adequate stability and watertight integrity, as well as factors affecting crew survivability, continue to compromise fishing vessel and crew safety. As the vessel sank and was not available for visual inspection, the condition of the watertight integrity of the vessel was evaluated. The analysis is presented within the context of these three elements.Analysis Problems associated with the lack of adequate stability and watertight integrity, as well as factors affecting crew survivability, continue to compromise fishing vessel and crew safety. As the vessel sank and was not available for visual inspection, the condition of the watertight integrity of the vessel was evaluated. The analysis is presented within the context of these three elements. Vessel Stability In the sea conditions encountered by the HopeBay, the working deck would have been periodically submerged by wave crests passing along the vessel's hull and would be awash through the freeing ports. In quartering or beam seas, the vessel would be rolling, and the combined effect of rolling and periodic submergence of the deck at side created an accumulation of water on deck. Under such circumstances, the effect of the sea state is considered a contributing factor, especially once the vessel reached Goose Bank and encountered the steep waves known to exist in that area of rapidly shallowing water. After analyzing the cumulative effect of wind, waves, and water on deck in the FLT condition, it was determined that the freeboard and the vessel's ability to right itself was reduced to about 55%of the STAB4 criteria. At this stage, with a relatively small reserve of stability and the deck periodically awash, the weathertight integrity of deck openings became critical. In case of any flooding, the vessel would be in a vulnerable condition, and any of the following factors would exacerbate the situation: movement of liquids in the slack diesel oil or fresh water tanks; rudder hard to port; extra weight from undocumented items; extra weight from fish trapped in the net on the after drum; varying buoyancy forces along the hull caused by moving through wave crests and troughs; height of some waves encountered by the vessel exceeding the significant wave height; and period of waves similar to the natural rolling period of the vessel. Considered individually and in a static environment, these factors should not have a serious adverse impact on the vessel's stability. However, in a dynamic environment, their cumulative effect could produce an additional heeling moment and heeling angle sufficient to overcome the small margin of stability, leading to the vessel's capsize. Downflooding through deck openings or the dutch door would ultimately have eliminated the vessel's ability to retain positive stability. As designed, the vessel should have had sufficient stability to withstand the sea conditions encountered. For it to have thus capsized, downflooding had to have taken place through deck openings into below-deck compartments. This is consistent with the study that concluded that the decks of the vessels with this design would be wet and that watertight integrity is paramount for safe operation of these vessels.19 Source of Downflooding There is no information to suggest that the hatch covers were defective. They were bolted down, and not used at sea during fishing operations, further reducing the likelihood of water ingress from this source. Closing arrangements for deck scuttles were similar to those of the manholes, and neither type of cover provided the operator with any indication that they were securely closed. It is therefore likely that either the manhole covers or the deck scuttles were the primary source of water ingress. As Nos. 1 and 2 fish holds were filled with fish, salt water, and ice, ingress of water through their respective manhole and fish scuttle covers would have had little effect on the vessel's stability. However, No.3 hold was empty- and it had sufficient capacity to capsize the vessel should it flood under the conditions prevalent at the time. As the deck scuttles for the No.3 hold had not been used for a number of years, this leaves the manhole opening to the No.3 hold as the most likely primary source of the downflooding. Calculations show that an opening as little as 3.5cm2- which would be consistent with a gap around a loose manhole cover- would flood half the compartment over a period of 10hours. Any flooding in excess of this would cause the vessel to heel. The upper part of the dutch door was open while the vessel was heeling heavily to starboard; ultimately, this would have created a major downflooding point, eliminating the vessel's ability to retain positive stability. Accessibility of Liferafts In this occurrence, the vessel capsized on top of the liferaft, rendering it inaccessible. In situations where the crew is forced to abandon a vessel, protection from the serious adverse effects of being immersed in cold water is a major factor in survival. Ideally, a crew, wearing immersion suits, attempts to abandon the vessel and board the liferaft without entering the water. To facilitate rapid abandonment, liferafts are to be stowed in a location from which they can be readily launched. However, it is common for liferafts to be positioned on top of the wheelhouse where they are unlikely to interfere with fishing operations. In such circumstances, crew members must make their way to the top of the wheelhouse to release a liferaft from its cradle. As the wheelhouse top does not always extend to the ship's side, and as there is no means to readily launch a liferaft from such a stowed position, crew members must lower it to the main deck before deploying it over the side of the vessel. The difficulty of completing this operation is significantly increased as a vessel pitches and rolls. A vessel's size and the limitations imposed by its operational requirements pose challenges for liferaft stowage. Some challenges include: A liferaft stowed at the main deck level forward of the accommodation will occasionally be subjected to wind and waves during inclement weather and can be lost at sea. A liferaft stowed high above the main deck level, or on the centre line, poses problems because it has to be manhandled in difficult circumstances. A liferaft positioned near either the port or starboard side will be difficult to launch if the vessel is heeling in the opposite direction. Taking into consideration the design and layout of the vessel, options are available to help ensure that liferaft stowage is in an optimum position for ready deployment. These include: a stowage location adjacent to the ship's side; a cradle design allowing the ready launch of the liferaft clear of the vessel's side; the provision of a mechanical launching mechanism with minimum maintenance requirements; and the provision of a physical barrier to prevent fouling of the rigging during launch. Immersion Suit Performance20 A properly fitted and well-maintained immersion suit is essential to prolonging survival in the water. The death of two crew members who were wearing abandonment suits would suggest that excessive sea water entered the suits, reducing their thermal protection. The pinhole on the right biceps of one suit, combined with likely leakage at the untucked wrist seals, and the unfastened neck and face seal zipper on the other suit, would account for this. Validation of Immersion Suit Testing Actual conditions of use will usually exceed testing-standard requirements. In practice, the wearer is likely to abandon a vessel under emergency circumstances that include hostile conditions such as open seas, large waves, swells, and near-freezing sea temperatures. The wearer may well have to swim face down while attempting to clear a sinking vessel, or have his or her face frequently covered by a series of approaching waves, some of which could exceed 40cm- the criteria established for suit testing.21 Moreover, because the swim test- an integral part of the standard- must be conducted in controlled facilities, the test has never been validated against realistic conditions. Universal Size and Testing Criteria The immersion suit standard uses both height and weight criteria for sizing. Testing methods for the universal size immersion suit may not account for all body types. As a result, some wearers may not properly fit into the universal suit size and may be at risk. The use of other criteria beyond height and weight might better aid suit design, allowing for improved fit of seals and more closely fitting suits.22 However, such an approach may also require more suit sizes, negating the principle of a universal suit size. Donning Drills Deaths due to inadequate maintenance and inspection of suits continue to be a problem. Although donning drills increase user familiarity with an immersion suit and reduce donning time, drills that include immersion in water can also ensure that: the suit is in a good state of repair, and the suit fits well and forms an effective seal at the face and wrists. Despite initiatives taken by regulatory agencies to educate fishers on the need to conduct donning drills, the problem persists. Buyers seldom take time to read suit instructions, nor do they don a suit prior to its purchase, and sellers seldom inform buyers of suits' features and limitations. Additionally, all necessary information is not always available at the point of sale. Fishers, therefore, will continue to be at risk of having both improperly sized and poorly maintained immersion suits which, when used in an emergency, will not provide the necessary level of thermal protection. A rigorous, targeted approach to raise awareness of the advantages of donning immersion suits on a periodic basis will help foster this practice and ensure that immersion suits are fit for their intended service. The loaded condition of the vessel and the sea conditions encountered made the vessel vulnerable to shipping water on deck and through the freeing ports. The vessel lost transverse stability in a manner consistent with the accumulated free surface effect of water shipped and retained on deck and water downflooding into interior spaces. It is most likely that water on deck first flooded into the No.3 hold through a leaking manhole cover or deck scuttle, and subsequently through the open dutch door, until the vessel lost all positive stability and capsized. An effective immersion suit drill, including immersion in water, would have identified incorrect sizing and maintenance-related issues.Findings as to Causes and Contributing Factors The loaded condition of the vessel and the sea conditions encountered made the vessel vulnerable to shipping water on deck and through the freeing ports. The vessel lost transverse stability in a manner consistent with the accumulated free surface effect of water shipped and retained on deck and water downflooding into interior spaces. It is most likely that water on deck first flooded into the No.3 hold through a leaking manhole cover or deck scuttle, and subsequently through the open dutch door, until the vessel lost all positive stability and capsized. An effective immersion suit drill, including immersion in water, would have identified incorrect sizing and maintenance-related issues. The design of the manhole cover has deficiencies that may allow water ingress and thus detrimentally affect stability. As the swim test used for testing immersion suits has never been validated against realistic weather and sea conditions, suit performance may be inadequate in conditions normally encountered. The universal size immersion suits may not fit every body type equally well, permitting excess water leakage into the suit and thereby reducing thermal protection. The common and less-than-optimal positioning of the liferaft on small fishing vessels hampers rapid deployment in an emergency, depriving the crew of valuable lifesaving equipment.Findings as to Risk The design of the manhole cover has deficiencies that may allow water ingress and thus detrimentally affect stability. As the swim test used for testing immersion suits has never been validated against realistic weather and sea conditions, suit performance may be inadequate in conditions normally encountered. The universal size immersion suits may not fit every body type equally well, permitting excess water leakage into the suit and thereby reducing thermal protection. The common and less-than-optimal positioning of the liferaft on small fishing vessels hampers rapid deployment in an emergency, depriving the crew of valuable lifesaving equipment. Safety Action Action Taken Standards for Marine Abandonment Suit Systems On 19 August 2004, the Transportation Safety Board (TSB) sent Marine Safety Advisory (MSA) 04/04 to the Marine Abandonment Immersion Suit System Committee of the Canadian General Standards Board (CGSB), identifying a concern that universal size immersion suits do not fit all body types equally well. In response, the committee amended the standard Immersion Suit Systems (CAN/CGSB-65.16-2005)23 so that the following information will be made available to purchasers of suits at the point of sale: the effectiveness of the suit system in preventing hypothermia and possibly death depends upon it fitting well enough to prevent the ingress of water; although the universal size immersion suit system has been designed to fit the majority of individuals, the suit does not fit all body types equally well; a reminder that each person takes the initiative, where possible, to ensure that his/her immersion suit system is properly sized; a description of the suit system; instructions for maintenance and cleaning; instructions concerning the fitting and operation of a personal locator light; instructions on the operation of the inflatable element, if any, and instructions on when and how to use it. The standard was also amended to require the following: proper donning procedures and other operational instruction on the use of the suit system shall be simple and obvious; instructions for donning and wearing shall be on the exterior of the stowage container; these instructions shall also be available in a form suitable for mounting on a bulkhead and insertion into the ship's training manual as applicable. The committee also indicated that Transport Canada has funded research to confirm the validity of the leakage test. This will include testing representative suits at sea under realistic conditions. In addition, TC has funded research to examine whether height and weight are the best criteria for designing universal-size suits, and, if not, to provide recommendations for improving the sizing criteria. Donning Drills and Durability Aspects of Immersion Suits On 12 October 2004, TSB sent MSA05/04 to TC, which was copied to the Marine Abandonment Immersion Suit System Committee of the CGSB, informing both parties of the potential deficiency associated with poor-fitting, poorly maintained immersion suits and the absence of regular donning of suits during safety drills. In response, TC indicated it would consider formally including the importance of regular maintenance and inspection of immersion suits in the syllabus of training courses for inspectors. In October2006, the Marine Safety National Training Program (NTP) incorporated the subject of maintenance and inspection of immersion suits, as part of the Lifesaving Module in the Vessel Inspection Course, which is mandatory for all Marine Safety Inspectors in Transport Canada. In a separate response to MSA 05/04, the Committee indicated it recommended to TC that it implement a program of regular donning drills, regular inspection, and maintenance schedules for suits, and that an expiry date be established to denote each suit's wearability. Marine Emergency Instruction Concerning Immersion Suits on Canadian Fishing Vessels On 01 November 2004, TSB sent MSA06/04 to all TC-approved Marine Emergency Duties (MED) course providers in Canada, which was copied to TC, again noting the safety risks associated with poor-fitting, poorly maintained immersion suits and the absence of regular donning of suits during safety drills. In response, TC indicated that it has revised TP4957- Marine Emergency Duties Training Program, after circulation to marine schools for comments. The final version of TP4957 will come into force at the same time as the relevant section of the new Canada Shipping Act,2001, on 01July2007. One immersion suit manufacturer has submitted for CGSB approval a set of printed donning instructions to be made available at the time of purchase. The instructions will advise the purchaser to: tuck in wrist seals, and obtain a complete inspection by a certified inspection/repair facility at least every two years. Adequacy of Single Cross Bar-Type Manhole Covers On 15 February 2005, TSB sent MSA 01/05 to TC concerning potential deficiencies associated with single cross bar-type manhole covers, specifically, of the potential for water to leak into below-deck compartments. TC responded that at the present time there is no requirement for manhole covers to be type-approved. However, the proposed Fishing Vessel Construction Standard, due to come into force in late2007, will require manhole covers to be type-approved and subjected to hose test. In the interim, TC is in the process of issuing a Ship Safety Bulletin (SSB) concerning the potential safety deficiencies of manhole covers. To date, no SSB has been issued. In June2005, Pacific Coast Fishermen's Mutual Marine Insurance Company advised its members, and the fishing industry as a whole, of the potential deficiencies associated with this type of manhole cover and its single-bar type of locking mechanism. Safety Concern The proposed Fishing Vessel Construction Standards were initially due to come into force in late 2006 but are now due in late 2007. These standards will require manhole covers to be type-approved and be subject to a hose test. Currently there are no requirements for such covers to be type-approved. In the interim, TCwas to consider issuing a Safety Bulletin to bring the potential safety deficiencies of these covers to the attention of mariners nationally. The issue was also to be brought to the attention of regional TCinspectors. To date, no Bulletin has been issued and the Board is concerned that the delay in issuing of the Fishing Vessel Construction Standards and the lack of a Bulletin warning the industry of the safety deficiencies relating to manhole covers continue to put vessels and their crews at risk.